Universal of North America Application Information - Dewey Insurance Agency, Inc. Cooper City, FL

Name(s) of all owners:*

Phone number:*

Can we text you at this phone number?*

Yes
No

EMAIL ADDRESSES FOR ALL SIGNERS: (The application must be signed by all applicants. We will send the forms to you to sign electronically. If you do not want to sign electronically please note how you would like the application sent to you.)*

Property address:*

Mailing address if different from property address:*

Applicant Marital Status:*

Date(s) of birth for all applicants:*

Any unrelated cohabitant(s) living in the household?*

Yes
No

If Yes, does the cohabitant(s) have an ownership interest?*

Yes
No
Not applicable

Any farming or other business conducted on premises (including day/child care)?*

No
Yes

During the last five years, has any applicant been convicted of any degree of the crime of arson?*

No
Yes

Seasonal or Secondary dwelling?*

No, owner occupied primary residence
No, rented primary residence
Yes

Number of months of consecutive UNoccupancy*

Any rental exposure?*

No
Yes

Does dwelling have a central station burglar and fire alarm? (IF YES, WE WILL NEED A CERTIFICATE FROM THE MONITORING COMPANY)*

No
Yes

Secured community or professional management firm?*

No
Yes

Overseen by reputable party within 50 miles of risk?*

No, this is my primary residence
No
Yes

Is there a swimming pool or hot tub on the premises?*

No
Yes

Does the swimming pool have a diving board and/or slide?*

No
Yes
No Pool

Is the pool or hot tub full of water?*

No
Yes
No Pool

Is there a screened pool enclosure?*

No
Yes
No Pool

Is the pool completely fenced or walled with minimum 4ft height?*

No
Yes
No Pool

Is the fence or wall of permanent construction?*

No
Yes
No Pool

Does the fence, wall or screen enclosure have a self-locking gate/door?*

No
Yes
No Pool

Fraternity, Sorority, or any other similar housing arrangement?*

No
Yes

Is the dwelling/building under construction or undergoing extensive renovation?*

No
Yes

Are there any pets on premises? If yes, list type of pet including the breed if pet is a dog:*

Any past history of a bite or attack for your pet?*

No
Yes
No pet

Is property currently occupied?*

No
Yes

Will home be owner occupied within 30 days?*

No
Yes
Yes, it is currently occupied

If the home is not currently occupied, provide move-in date:*

Is the dwelling a modular home, mobile home, trailer home, house trailer, pre-fab or travel trailer?*

No
Yes

Is the structure constructed partially or entirely over water?*

No
Yes

Is there a trampoline on premises?*

No
Yes

Is the dwelling built on stilts or pilings?*

No
Yes

Any flooding, brush, forest fire hazard, landslide, etc?*

No
Yes

Is dwelling built on a landfill previously used for refuse?*

No
Yes

Is there a daycare on premises?*

No
Yes

If there is a home day care, has the insured provided a copy of the state or county license?*

No
Yes
N/A

If there is a home day care, has the insured provided a copy of the commercial liability policy with coverage equal to or greater than their personal limit?*

No
Yes
N/A

Has the insured ever been canceled or non-renewed for material misrepresentation or insurance fraud, or ever convicted of arson?*

No
Yes

Is there any commercial or non-habitational use?*

No
Yes

If a fuel oil tank is on premises, has other insurance been obtained for the tank? (Give First Party and limit, and Third Party and limit)*

Are there any All Terrain Vehicles (ATV's) kept or used on the premises?*

No
Yes

Is there a skateboard ramp or bicycle ramp on premises?*

No
Yes

Is the property condemned due to condition, located in a condemned area or in an area scheduled to be condemned due to urban renewal or highway construction?*

No
Yes

Is there any prior or current sinkhole activity on the premises whether or not it resulted in a loss to the dwelling, to the best of the applicant/insured's knowledge?*

No
Yes

Any residence employees?*

No
Yes

Any other residence owned, occupied, or rented?*

No
Yes

Is property situated on more than 5 acres?*

No
Yes

Any coverage declined, canceled, or non-renewed during the last 3 years?*

No
Yes

Has applicant had a foreclosure, repossession or bankruptcy during the past 5 years?*

No
Yes

Is property located within two miles of tidal water?*

No
Yes

Does applicant own any recreational vehicles (snow mobiles, dune buggies, mini bikes, etc.)? List year, type, make, model.*

Is house for sale?*

No
Yes
Yes, I am currently buying the house

Is property within 300 feet of a commercial or non-residential property?*

No
Yes

Was the structure originally built for other than a private residence and then converted?*

No
Yes

Any lead paint hazard?*

No
Yes

Any existing damage/disrepair?*

No
Yes

Is the insured requesting additional loss assessments coverage?*

No
Yes

If yes, have any association losses occurred to which this coverage may apply?*

No
Yes
N/A

Was golf cart coverage requested?*

No
Yes

Are there any aluminum framed screened enclosures or carports?*

No
Yes

I have read and agree with the responses to all questions on this page.*

Agree
Disagree